Approach Considerations

The treatment of choriocarcinoma includes orchidectomy, chemotherapy, and retroperitoneal lymph node dissection.
[7] High-dose chemotherapy with autologous stem cell rescue has been used in patients with incomplete responses to initial therapy.
[16] A multimodal approach involving the urologist and hematologist/oncologist is essential in the treatment of advanced nonseminomatous germ cell tumors.

Standard chemotherapy for good-to-poor–risk NSGCT is with bleomycin, etoposide, and cisplatin (BEP) for four cycles. Additional agents include vinblastine and ifosfamide.

Pure choriocarcinoma, an extremely rare variant comprising less than 1% of NSGCT cases, is not as sensitive to chemotherapy as mixed NSGCT. The authors' exhaustive search of major textbooks and the literature revealed no clear guidelines as to how to treat these patients. Most case reports describe patients presenting with advanced metastatic disease, with varying responses to chemotherapy. In general, standard chemotherapy for poor-risk NSGCT is the initial therapy. However, these patients may require salvage regimens and may benefit from referral to a major cancer center to be treated under protocols that can involve cyclical regimens or dose escalation with growth factor/stem cell support. Cases responsive to chemotherapy may require additional surgical debulking.

Further, as described by Logothetis et al (1986), choriocarcinoma syndrome entails hemorrhage from metastatic sites of choriocarcinoma corresponding with significant elevation of beta-hCG.
[17] This clinical presentation, although rare, is life-threatening and requires immediate treatment.
[18]

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Surgical Care

Radical inguinal orchiectomy

Preoperative details are as follows:

Serum tumor markers must be drawn preoperatively because they fall rapidly postorchiectomy. Other staging tests can be performed preoperatively or postoperatively.

Because of the rapid doubling time of a potential choriocarcinoma, testis tumors are often scheduled for surgery rapidly to avoid upstaging.

Most patients with testicular choriocarcinoma are young and healthy and require only routine preoperative preparation.

Semen donation for subsequent fertility should be discussed if the contralateral testis function is in question; however, many patients with poor semen quality demonstrate improvement after orchiectomy.

Cosmetic testicular prostheses are readily available to interested patients. Coloplast, formerly Mentor, has an FDA-approved saline-filled testicular prosthesis that has been in use since 2002. This prosthesis can be placed at a later date, if desired, in an outpatient procedure. Bodiwala et al (2007) published an excellent review article on rationale and patient discussion.
[19]

In a patient who presents with symptomatic metastatic lesions from a testis tumor, proceeding with platinum-based chemotherapy and delaying radical orchiectomy is reasonable. Radical orchiectomy is not a very morbid procedure but may delay the initiation of chemotherapy.

Differentiation of seminoma versus NSGCT for advanced disease is not important at the outset of treatment, as both groups receive the same regimen.

Although chemotherapy may result in disappearance of the testicular mass, orchiectomy is always indicated.

Intraoperative details are as follows:

Spinal, general, or (uncommonly) local anesthesia may be used. The inguinal area is shaved and prepared in standard fashion.

An inguinal incision is made to allow exposure of the external and internal iliac canal.

The external iliac fascia is opened, exposing the spermatic cord and the internal iliac canal. The spermatic cord is controlled with a Penrose drain in tourniquet fashion to stop retroperitoneal lymphatic and venous drainage of tumor cells.

The testis is then delivered from the scrotum, and the vas deferens and spermatic arteries are ligated separately.

A long nonabsorbable tie is left on the patient side of the spermatic cord to facilitate identification should retroperitoneal lymph node dissection become necessary, requiring dissection of the remaining spermatic cord structures from the abdominal exposure.

The external oblique fascia is reapproximated and the skin closed in standard fashion.

Postoperative details are as follows:

Radical orchiectomy is usually an outpatient procedure or is performed as a 23-hour admission, often accompanied by the staging workup.

As follow-up, patients are staged and referred for the appropriate adjuvant therapies.